Neurosurgery resident presentation

1. MUMTAZ ALI
JPMC KARACHI

2. Anatomy
 Cerebellum : posteriorly
 brainstem : anteriorly
 middle cerebellar peduncle : laterally
 aqueduct of Sylvius to the obex
 ventral floor : dorsal surface of the lower midbrain

3.  lateral wall : superior, middle, and inferior
cerebellar peduncles
 lateral recess
 superior part of the roof : lingula, the superior
medullary velum, and the fastigium
 inferior part of the roof : tela choroidea, the
choroid plexus, the inferior medullary velum, the
uvula and nodulus of the vermis

4. Ependymomas
 most common
 2–3%
 Ependymal cells
 lower floor of the fourth ventricle
 occupy : ventricular cavity
 extend : foramen of Luschka or foramen of Magendie
 soft, grayish or red tumors : cysts or mineral
calcifications
 ultrasonic aspirator

5.  Types :
myxopapillary ependymomas
subependymomas,
Ependymomas
anaplastic ependymomas
 Grading :
Similarty to ependymal cells
 10–15% spread : CSF

7. Medulloblastomas
 Primitive underdeveloped cells
 childhood
 1st described : Harvey Cushing (1930)
 Spongioblastoma cerebelli ; a soft suckable tumor
 7 %

8.  not invade the floor of the fourth ventricle
 middle cerebellar peduncles
 completely filled with tumor up to the aqueduct
 neuraxis and cerebellum
 highly vascularized

11. Hemangioblastomas
 highly vascularized lesions
 PICA and choroid plexus
 digital subtraction angiograms
 cannot be debulked because of their typical
morphology

13. Epidermoid Cysts
 fill the fourth ventricle completely and expand into the
lateral recess
 separated by firm arachnoid membranes

15. Pilocytic Astrocytomas
 well-circumscribed
 Very rare tumor

17. Clinical Features
 deep location within the brain
 neural and vascular structures
 CSF physiology alteration
 compressive or destructive effects

18.  Headache
 Vertigo
 Nausea and vomitting sec to Acute HCP
 motor weakness
 memory deficits
 gait disturbances

19. Investigations
 Routine :
cbc
suce
pt/aptt/inr
LFT
Hep B and C
chest xray
Ecg and Echo
G/A fitness

20.  Specific :
CT scan
MRI
Angiogram
DSA
• Relevant :
Perimetry
visual acuity
fundoscopy

21. Surgery

22.  Tumors often hidden :
Vermis
the cerebellar tonsils
part of the cerebellar hemispheres
Brain stem
• tumor extends through the foramen of Luschka :
Cerebellomedullary cisterns
Premedullary cisterns
Prepontine cisterns
anterior spinal cisterns

23.  has relation :
cranial nerves
 vertebral arteries
basilar arteries

24. Transvermian approach
 splitting the vermis : Dandy
 vermal split syndrome :
removal of midline tumors involving the vermis
disturbed coordination of tandem gait
neurobehavioral changes

25. Telovelar Approach
 Transcerebellomedullary fissure approach
 standard median suboccipital craniotomy
 transverse sinus to the foramen magnum
 Sitting or prone
 C1 lamina
 The dura : Y-shaped fashion
 arachnoid membranes
 PICA and its branches

26.  cerebellomedullary fissure
 telovelar incision :
opening of the tela choroidea
inferior medullary velum
incision of the tela

28. Complications
 Intraoperative :
Injury to PICA
Injury to CN
Injury to vertebral arteries
 Postoperative :
HCP
CSF leak
Seizure
Cognitive functions
Wound infection

29. THANKYOU